MEDICARE IMAGING 

ACCREDITATION

Effect on Access to 

Advanced Diagnostic 

Imaging Is Unclear 

amid Other Policy 

Changes

Report to Congressional Committees

April 2014

GAO-14-378

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-378, a report to 

congressional committees

April 2014

MEDICARE IMAGING ACCREDITATION

Effect on Access to Advanced Diagnostic Imaging Is 

Unclear amid Other Policy Changes

Why GAO Did This Study

The Medicare Improvements for 

Patients and Providers Act of 2008 

(MIPPA) required that beginning 

January 1, 2012, suppliers that 

produce the images for Medicarecovered ADI services in office settings, 

such as physician offices, be 

accredited by an organization 

approved by CMS. MIPPA mandated 

that GAO issue two reports on the 

effect of the accreditation requirement. 

The first report, issued in 2013, 

assessed CMS’s standards for the 

accreditation of ADI suppliers and its 

oversight of the accreditation 

requirement.

In this report, GAO examined the effect 

the accreditation requirement may 

have had on beneficiary access to ADI 

services provided in the office setting. 

To do this, GAO examined trends in 

the use of the three ADI modalities—

CT; MRI; and NM, including PET—

provided to Medicare beneficiaries 

from 2009 through 2012 that were 

subject to the ADI accreditation 

requirement. GAO also interviewed 

CMS officials, representatives of the 

Intersocietal Accreditation Commission 

and the American College of 

Radiology—the two CMS-approved 

accrediting organizations that 

accounted for about 99 percent of all 

accredited suppliers as of January 

2013; and 19 accredited ADI suppliers 

that reflected a range of geographic 

areas, imaging services provided, and 

accrediting organizations used. In 

addition, GAO reviewed relevant 

literature to understand the context of 

any observed changes in ADI services 

throughout the period studied.

What GAO Found

GAO found that the number of advanced diagnostic imaging (ADI) services 

provided to Medicare beneficiaries in the office setting—an indicator of access to 

those services—began declining before and continued declining after the 

accreditation requirement went into effect on January 1, 2012. In particular, the 

rate of decline from 2009 to 2010 was similar to the rate from 2011 to 2012 for 

magnetic resonance imaging (MRI); computed tomography (CT); and nuclear 

medicine (NM), including positron emission tomography (PET) services. These 

results suggest that the overall decline was driven, at least in part, by factors 

other than accreditation. The percentage decline in the number of ADI services 

provided in the office setting was generally similar in both urban and rural areas 

during the period GAO studied.

Number of Advanced Diagnostic Imaging Services in the Office Setting per 1,000 Medicare 

Fee-for-Service Beneficiaries, by Modality, 2009-2012

The effect of accreditation on access is unclear in the context of recent policy 

and payment changes implemented by Medicare and private payers. For 

example, the Centers for Medicare & Medicaid Services (CMS) reduced 

Medicare payment for certain CT and MRI services, which could have 

contributed to the decline in the number of these services. Officials from CMS, 

representatives from the accrediting organizations, and accredited ADI suppliers 

GAO interviewed suggested that any effect of the accreditation requirement on 

access was likely limited.

The Department of Health and Human Services stated that it had no comments 

on a draft of this report.

View GAO-14-378. For more information, 

contact James Cosgrove at (202) 512-7114 or 

cosgrovej@gao.gov.
Page i GAO-14-378 Medicare Imaging Accreditation

Letter 1 

Background 5

Effect of Accreditation Requirement on Access to Advanced 

Diagnostic Imaging in Office Settings Is Unclear in Context of 

Other Policy Changes 10

Agency Comments 14

Appendix I Advanced Diagnostic Imaging Services in Office Settings per 1,000 

Medicare FFS Beneficiaries, 2010-2012 16

Appendix II GAO Contact and Staff Acknowledgments 17

Figures

Figure 1: Number of Advanced Diagnostic Imaging Services in the 

Office Setting per 1,000 Medicare Fee-for-Service 

Beneficiaries, by Modality, 2009-2012 10

Figure 2: Number of Advanced Diagnostic Imaging Services in the 

Office Setting per 1,000 Medicare Fee-for-Service 

Beneficiaries, by Urban/Rural Location, 2009-2012 11

Contents
Page ii GAO-14-378 Medicare Imaging Accreditation

Abbreviations

ACR American College of Radiology

ADI advanced diagnostic imaging

ATRA American Tax Relief Act of 2012

CMS Centers for Medicare & Medicaid Services

CT computed tomography

CPT Current Procedural Terminology

FFS fee-for-service 

HCERA Health Care and Education Reconciliation Act of 2010

IAC Intersocietal Accreditation Commission

IDTF independent diagnostic testing facility

MedPAC Medicare Payment Advisory Commission

MIPPA Medicare Improvements for Patients and Providers Act 

 of 2008

MPPR multiple procedure payment reduction

NM nuclear medicine

OPPS outpatient prospective payment system

PET positron emission tomography

PPACA Patient Protection and Affordable Care Act

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately.
Page 1 GAO-14-378 Medicare Imaging Accreditation

441 G St. N.W.

Washington, DC 20548

April 18, 2014

Congressional Committees

Advanced diagnostic imaging (ADI) services, such as computed 

tomography (CT), magnetic resonance imaging (MRI), and nuclear 

medicine (NM), allow physicians to diagnose life-threatening diseases like 

cancer and heart disease with greater speed and precision.1 However, 

problems such as inadequately trained technologists or poorly functioning 

equipment can lead to duplicative or inaccurate imaging tests, 

unnecessary exposure to radiation, missed or inaccurate diagnoses, and 

inappropriate treatment. The Medicare Improvements for Patients and 

Providers Act of 2008 (MIPPA) required that beginning January 1, 2012, 

suppliers of the technical component of ADI services—specifically CT, 

MRI, and NM, including positron emission tomography (PET)2

—be 

accredited by a designated accrediting organization in order to receive 

Medicare payment for these services.3 The requirement applies to ADI 

services provided in office settings, including physician offices and 

independent diagnostic testing facilities (IDTF), which are paid under the 

physician fee schedule.4 MIPPA accreditation does not apply to ADI 

services provided in institutional settings, including hospital inpatient or 

outpatient departments, which are not paid under the physician fee 

schedule.5

 

1

There are six types of medical imaging capabilities, referred to as modalities: CT; MRI; 

NM; ultrasound; X-ray and other standard imaging; and procedures that use imaging, such 

as using ultrasound to localize a needle when performing a biopsy.

MIPPA outlined broad criteria that accrediting organizations 

should use to evaluate ADI suppliers, such as standards for qualifications 

2

MIPPA also provided for the inclusion of certain other diagnostic imaging services as 

specified by CMS in consultation with physician specialty organizations and other 

stakeholders.

3

Pub. L. No. 110-275, § 135(a), 122 Stat. 2494, 2532 (codified at 42 U.S.C. § 1395m(e)). 

Medicare divides payment for ADI services into two components: the technical 

component, which is the production of the image, and the professional component, which 

is a physician’s interpretation of the image and report on the findings.

4

IDTFs are facilities that are independent of a hospital and physician office and provide 

only outpatient diagnostic services. 

5

For this report, we use the term “institutional settings” to refer to services provided in 

settings such as hospital inpatient departments, hospital outpatient departments, and 

emergency rooms.
 

Page 2 GAO-14-378 Medicare Imaging Accreditation

of personnel and standards to ensure the safety of beneficiaries and staff. 

The Centers for Medicare & Medicaid Services (CMS) administers and 

oversees the MIPPA accreditation requirement on behalf of the Secretary 

of Health and Human Services and has selected four organizations to 

serve as designated accrediting organizations—the American College of 

Radiology (ACR), the Intersocietal Accreditation Commission (IAC), The 

Joint Commission, and RadSite. In order to become accredited, ADI 

suppliers must select one of the accrediting organizations and undergo an 

accreditation review process to demonstrate that they meet the 

organization’s standards. Although the accreditation requirement has the 

potential to improve the quality and safety of ADI services, it could 

potentially disrupt Medicare beneficiaries’ access to ADI services if some 

suppliers are unwilling or unable to become accredited and, as a result, 

stop furnishing ADI services to Medicare beneficiaries.

MIPPA mandated that we issue a preliminary report in 2013 and a final 

report in 2014 on the effect of the accreditation requirement administered 

by CMS. Our first report, issued in May 2013, assessed CMS’s standards 

for the accreditation of ADI suppliers as well as its oversight of the 

accreditation requirement.6

To examine the effect the accreditation requirement may have had on 

beneficiary access to ADI services in the office setting, we identified 

trends in the number of these services provided to Medicare 

We found that CMS did not establish 

minimum national standards for the accreditation of suppliers of ADI 

services, but rather relied on its selected accrediting organizations to 

establish their own standards for quality and safety. We also found that 

CMS’s oversight of the accreditation requirement was limited, as the 

agency focused its initial oversight efforts on ensuring that claims were 

paid only to accredited suppliers. We recommended, among other things, 

that the Administrator of CMS determine the content of and publish 

minimum national standards for the accreditation of ADI suppliers and 

develop an oversight framework for evaluating accrediting organization 

performance. The Department of Health and Human Services, which 

oversees CMS, concurred with our recommendations. This final report 

examines the effect, if any, of the accreditation requirement on 

beneficiary access to ADI services provided in the office setting.

 

6

See GAO, Medicare Imaging Accreditation: Establishing Minimum National Standards 

and an Oversight Framework Would Help Ensure Quality and Safety of Advanced 

Diagnostic Imaging Services, GAO-13-246 (Washington, D.C.: May 31, 2013).
 

Page 3 GAO-14-378 Medicare Imaging Accreditation

beneficiaries—an indicator of access—before and after the accreditation 

requirement went into effect. We examined these trends for each of the 

three ADI modalities—CT; MRI; and NM, including PET—using Medicare 

Part B Carrier claims from 2009 through 2012, which were the most 

recent data available at the time of our analysis.7 We limited our analysis 

to the technical component of those services that were provided in the 

office setting, as the professional component is not subject to the 

accreditation requirement. We further limited the ADI services in our study 

to those Current Procedural Terminology (CPT) codes that are subject to 

ADI accreditation, according to CMS.8 We excluded certain codes to 

ensure that our results reflected trends in the number of ADI services 

rather than changes in billing practices. Specifically, because CPT codes 

can change over time, we excluded any codes from CMS’s list that were 

not billed at least once each year from 2009 to 2012. We also excluded 

CPT codes for any services that were combined, or “bundled,” with 

another service at any time during our study period. After these 

exclusions, the codes we analyzed represented 171 of the 219 CPT 

codes (78 percent) subject to the ADI accreditation requirement and 

75 percent of Medicare-covered ADI services in 2012 that were subject to 

the requirement.9 Using claims data for these CPT codes, we analyzed 

trends in the number of ADI services provided to Medicare beneficiaries, 

both at the national level and separately for urban and rural areas 

nationwide, before and after January 1, 2012, the date the accreditation 

requirement went into effect.10

 

7

PET is a nuclear imaging technique in which radioactive substances are administered to 

a patient and tracked by a radiation detector to render time-lapse images of the substance 

as it moves through the body. We have combined both NM and PET for the purposes of 

this report.

Specifically, we examined the total number 

8

CPT codes and their definitions are developed by the American Medical Association and 

used by physicians and other providers to identify health care services for billing 

purposes. According to CMS officials, the list of CPT codes subject to ADI accreditation 

was developed with input from a CMS staff radiologist and radiologic technicians, and is 

updated annually to incorporate coding changes. At the time of our study, the most current 

list available of CPT codes subject to ADI accreditation was published in May 2012.

9

Of the 171 CPT codes for ADI services in our analysis, 37 codes were for CT services, 

55 codes were for MRI services, and 79 codes were for NM/PET services.

10We defined urban areas as those within a Metropolitan Statistical Area (MSA). An MSA 

consists of one or more counties that contain a core urban area with a population of 

50,000 or more as well as adjacent counties that have a high degree of social and 

economic integration with the urban core, as measured by commuting ties. We defined 

rural areas as those that were not located within an MSA.
 

Page 4 GAO-14-378 Medicare Imaging Accreditation

of CT, MRI, and NM/PET services in the office setting per 1,000 Medicare 

fee-for-service (FFS) beneficiaries each year from 2009 to 2012.11

We also interviewed CMS officials, representatives of IAC and ACR—the 

two CMS-approved accrediting organizations that accounted for about 

99 percent of all accredited suppliers as of January 2013,

In 

2012, approximately 21 percent of ADI services included in our study 

were provided in the office setting, while the remaining 79 percent were 

provided in the institutional setting. Although our analyses provide insight 

into the extent to which the accreditation requirement may have affected 

access to ADI services in the office setting, we did not determine whether 

a given level of utilization indicated sufficient access or whether changes 

in ADI service use were medically appropriate. We assessed the reliability 

of the data from CMS that we analyzed by reviewing relevant 

documentation and examining the data for obvious errors. We determined 

that the data were sufficiently reliable for the purposes of our study.

12 and 19 

accredited ADI suppliers to obtain their perspectives on the effect of 

accreditation on beneficiary access to ADI services.13

We conducted this performance audit from July 2013 to April 2014 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

In addition, we 

reviewed relevant literature on trends in imaging to better understand the 

context of any observed changes in ADI services throughout the time 

period we studied.

 

11Examining the number of services per 1,000 Medicare FFS beneficiaries allows us to 

account for changes in the Medicare population, such as baby boomers who age into 

Medicare and/or beneficiaries who enroll in Medicare Advantage plans. To calculate the 

number of Medicare FFS beneficiaries from 2009 through 2012, we used the Master 

Beneficiary Summary File, a database that contains enrollment information for all 

Medicare beneficiaries enrolled in a given year.

12We did not interview suppliers accredited by The Joint Commission because of the small 

number of suppliers accredited by the organization as of January 2013. In addition, we did 

not include suppliers accredited by RadSite as it had not been designated as a CMSapproved accrediting organization when we interviewed suppliers.

13As a group, these suppliers represented both urban and rural locations, a range of 

states nationwide, and each of the three ADI modalities. Of the 19 suppliers we selected, 

12 were located in urban areas, 3 were in rural areas, and 4 were in both rural and urban 

areas; these 19 suppliers were located in 14 states. The suppliers we interviewed were 

accredited by ACR (11 suppliers), IAC (5 suppliers), or both (3 suppliers).
 

Page 5 GAO-14-378 Medicare Imaging Accreditation

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

CT uses ionizing radiation and computers to produce cross-sectional 

images of internal organs and body structures. MRI uses powerful 

magnets, radio waves, and computers to create cross-sectional images of 

internal body tissues. NM uses radioactive materials in conjunction with 

an imaging modality to produce images that show both structure and 

function within the body. During an NM service, such as a PET scan, a 

patient is administered a small amount of radioactive substance, called a 

radiopharmaceutical or radiotracer, which is subsequently tracked by a 

radiation detector outside the body to render time-lapse images of the 

radioactive material as it moves through the body. Imaging equipment 

that uses ionizing radiation—such as CT and NM—poses greater 

potential short- and long-term health risks to patients than other imaging 

modalities, such as ultrasound. This is because ionizing radiation has 

enough energy to potentially damage DNA and thus increase a person’s 

lifetime risk of developing cancer. In addition, exposure to very high 

doses of this radiation can cause short-term injuries, such as burns or 

hair loss.

To become accredited, ADI suppliers must select a CMS-designated 

accrediting organization, pay the organization an accreditation fee, and 

demonstrate that they meet the organization’s standards. As we noted in 

our May 2013 report, the accrediting organization fees vary.14

 

14See 

For 

example, as of January 2013, ACR’s accreditation fees ranged from 

$1,800 to $2,400 per unit of imaging equipment, while IAC’s fees ranged 

GAO-13-246. 

Background

Imaging Modalities

ADI Accreditation Process 

and CMS Oversight
 

Page 6 GAO-14-378 Medicare Imaging Accreditation

from $2,600 to $3,800 per application.15 While the specific standards 

used by accrediting organizations vary, MIPPA requires all accrediting 

organizations to have standards in five areas: (1) qualifications of medical 

personnel who are not physicians and who furnish the technical 

component of ADI services, (2) qualifications and responsibilities of 

medical directors and supervising physicians, (3) procedures to ensure 

that equipment used in furnishing the technical component of ADI 

services meets performance specifications, (4) procedures to ensure the 

safety of beneficiaries and staff, and (5) establishment and maintenance 

of a quality-assurance and quality control program.16 To demonstrate that 

they meet their chosen accrediting organization’s standards, ADI 

suppliers must submit an online application as well as required 

documents, which could include information on qualifications of personnel 

or a sample of patient images.17

MIPPA requires CMS to oversee the accrediting organizations and 

authorizes CMS to modify the list of selected accrediting organizations, if 

necessary. Federal regulations specify that CMS may conduct “validation 

audits” of accredited ADI suppliers and provide for the withdrawal of CMS 

approval of an accrediting organization at any time if CMS determines 

that the organization no longer adequately ensures that ADI suppliers 

meet or exceed Medicare requirements.18

 

15ACR’s fees vary by modality, and discounted fees are available for facilities with more 

than one imaging unit and multiple modalities. IAC’s fees vary by modality and cover the 

first unit of imaging equipment for MRI and CT; the fee for NM and PET covers all of the 

equipment. For MRI and CT, IAC offers discounted fees for each additional unit for 

facilities with more than one imaging unit. For all modalities, IAC offers a discount for 

facilities with more than one site. Neither organization’s fees include additional costs that 

suppliers may incur to obtain accreditation, such as fees paid to a consultant or for the 

purchase of a phantom, which is a solid object designed to mimic critical imaging 

characteristics of patients, such as bone and tissue, that is imaged using suppliers’ 

equipment to help assess performance parameters such as resolution and image 

uniformity.

CMS also has requirements for 

accrediting organizations. For example, accrediting organizations are 

responsible for using mid-cycle audit procedures, such as unannounced 

site visits, to ensure that accredited suppliers maintain compliance with 

16MIPPA also provided for the inclusion of any additional standards CMS determines 

appropriate.

17Depending on their chosen accrediting organization, suppliers may also be subject to an 

on-site visit prior to accreditation.

1842 C.F.R. § 414.68(h).
 

Page 7 GAO-14-378 Medicare Imaging Accreditation

MIPPA’s requirements for the duration of the 3-year accreditation cycle. 

According to CMS officials, five full-time staff are budgeted to oversee 

and develop standards for the ADI accreditation requirement.19 Since our 

report was issued in May 2013, CMS has begun to gather input from 

stakeholders on the development of national standards for the 

accreditation of ADI suppliers, which it intends to develop by the end of 

2014.

Medicare payment for the technical component of ADI services is 

intended to cover the cost of the equipment, supplies, and nonphysician 

staff and is generally significantly higher than the payment for the 

professional component. The payment for the professional component is 

intended to cover the physician’s time in interpreting the image and 

writing a report on the findings. Medicare reimburses providers through 

different payment systems depending on where an ADI service is 

performed. When an ADI service is performed in an office setting such as 

a physician’s office or IDTF, both the professional and technical 

component are billed under the Medicare physician fee schedule.

Alternatively, when the ADI service is performed in an institutional setting, 

the physician can only bill the Medicare physician fee schedule for the 

professional component, while the payment for the technical component 

is covered under a different Medicare payment system, according to the 

setting in which the service is provided. For example, the technical 

component of an ADI service provided in a hospital outpatient department 

is paid under the hospital outpatient prospective payment system 

(OPPS).

 

19CMS officials stated that these budgeted staff do not include staff involved with the 

processing of payments for ADI services.

Medicare Payment and 

Billing Policies for ADI 

Services
 

Page 8 GAO-14-378 Medicare Imaging Accreditation

The use of imaging services grew rapidly during the decade starting in 

2000—MedPAC reported that cumulative growth between 2000 and 2009 

totaled 85 percent20—although the rate of growth has declined in recent 

years.21

• The Deficit Reduction Act of 2005 required that, beginning January 1, 

2007, Medicare payment for certain imaging services under the 

physician fee schedule not exceed the amount Medicare pays under 

the OPPS.

Growth in imaging utilization and expenditures—including those 

for ADI services—prompted action from Congress, CMS, and private 

payers. Congress has enacted legislation to help ensure appropriate 

Medicare payment for ADI services; in some cases, this legislation has 

had the effect of reducing Medicare payment for the technical component 

of certain imaging services, such as the following:

22

• The Patient Protection and Affordable Care Act (PPACA), as 

amended by the Health Care and Education Reconciliation Act of 

2010 (HCERA) and the American Tax Relief Act of 2012 (ATRA), 

reduced payment for the technical component of ADI services by 

adjusting assumptions, known as utilization rates, related to the rate 

at which certain imaging equipment is used.23

 

20MedPAC, Report to the Congress: Medicare Payment Policy (Washington, D.C.: March 

2013). See also GAO, Medicare Part B Imaging Services: Rapid Spending Growth and 

Shift to Physician Offices Indicate Need for CMS to Consider Additional Management 

Practices,

These changes had the 

effect of reducing payments for the technical component of ADI 

GAO-08-452 (Washington, D.C.: June 13, 2008).

21A recent study found that the use of MRI in Medicare slowed from an annual growth rate 

of 14 percent during 2000 through 2005 to an average of 2.6 percent per year from 2006 

through 2009. See D.W. Lee and F. Levy, “The Sharp Slowdown in Growth of Medical 

Imaging: An Early Analysis Suggests Combination of Policies was the Cause,” Health

Affairs, vol. 31, no. 8 (2012).

22Pub. L. No. 109-171, § 5102(b), 120 Stat. 4, 39-40 (2006) (codified at 42 U.S.C. 

§ 1395w-4). 

23Pub. L. No. 111-148, § 3135(a), 124 Stat. 119, 436 (2010), as amended by Pub. L. 

No, 111-152, § 1107, 124 Stat. 1029, 1050, which we refer to collectively as PPACA; 

Pub. L. No. 112-240, § 635, 126 Stat. 2313, 2356. Utilization rates are taken into account 

when calculating technical component payments for ADI services. Higher utilization rates 

correspond to lower technical component payments. CMS used a 50 percent utilization 

rate in 2009. In 2010, CMS began transitioning to a 90 percent utilization rate, with the 

intent of completing the transition over a 4-year period, for equipment priced at over 

$1 million—primarily affecting CT and MRI services. However, PPACA, as amended by 

HCERA, changed the rate to 75 percent beginning in January 2011. ATRA increased the 

utilization rate for this equipment to 90 percent beginning in January 2014. 

Laws and Policies 

Designed to Control 

Imaging Utilization and 

Expenditures
 

Page 9 GAO-14-378 Medicare Imaging Accreditation

services beginning in January 2011, with additional reductions 

scheduled to take effect in 2014.

CMS implemented additional changes to Medicare payment policy to help 

ensure appropriate payment for ADI services, which had the effect of 

reducing Medicare payment for certain imaging services. In January 2006 

CMS began applying a multiple procedure payment reduction (MPPR) 

policy to the technical component of certain CT and MRI services, which 

reduces payments for these services when they are furnished together by 

the same physician, to the same patient, on the same day.24

Private payers have also implemented policies designed to help control 

imaging utilization and expenditures. One such policy is the use of prior 

authorization, which can involve requirements that physician orders of 

imaging services meet certain guidelines in order to qualify for payment.

Beginning in 

January 2012, CMS expanded the MPPR by reducing payments for the 

lower-priced professional component of certain CT and MRI services by 

25 percent when two or more services are furnished by the same 

physician to the same patient, in the same session, on the same day.

25

Further, best practice guidelines, such as ACR’s Appropriateness Criteria, 

as well as efforts to educate physicians and patients about radiation 

exposure associated with imaging, have been used to promote the 

appropriate use of imaging services.26

 

24In calendar year 2006, CMS began reducing the payment for the technical component of 

the lower-priced imaging service by 25 percent when multiple CT or MRI services are 

performed on contiguous body parts during the same session. See Medicare Program: 

Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 

2006, 70 Fed. Reg. 70116 (Nov. 21, 2005). In addition, PPACA increased the payment 

reduction from 25 percent to 50 percent beginning July 1, 2010. See Pub. L. No. 111-148, 

§ 3135(b), 124 Stat. 119, 437.

25Although as of August 2013 FFS Medicare did not require prior authorization, we 

recommended in 2008 that, to address the rapid growth in Medicare Part B imaging 

expenditures, CMS consider adopting prior authorization and privileging (that is, limiting 

the authority to order certain services to only providers in certain specialties). See 

GAO-08-452. 

26The ACR Appropriateness Criteria are evidence-based guidelines intended to assist 

referring physicians and other providers in making the most appropriate imaging or 

treatment decision for a specific clinical condition.
 

Page 10 GAO-14-378 Medicare Imaging Accreditation

We found that the number of ADI services provided to Medicare 

beneficiaries in the office setting—an indicator of access to those 

services—began declining before and continued declining after the 

accreditation requirement went into effect on January 1, 2012 (see fig. 1). 

In particular, the rate of decline from 2009 to 2010 was similar to the rate 

from 2011 to 2012 for the CT; MRI; and NM, including PET, services in 

our analysis. These results suggest that the overall decline was driven, at 

least in part, by factors other than accreditation. For example, the number 

of CT services per 1,000 FFS beneficiaries declined by 9 percent 

between 2009 and 2010, 4 percent between 2010 and 2011, and 

9 percent between 2011 and 2012.

Figure 1: Number of Advanced Diagnostic Imaging Services in the Office Setting 

per 1,000 Medicare Fee-for-Service Beneficiaries, by Modality, 2009-2012

Notes: To examine the total number of advanced diagnostic imaging (ADI) services provided in the 

office setting per 1,000 Medicare fee-for-service beneficiaries, we calculated the number of claims for 

the technical component of computed tomography; magnetic resonance imaging; and nuclear 

medicine, including positron emission tomography services each year. Our results were limited to 

selected services subject to the ADI accreditation requirement. We excluded services that were not 

billed at least once each year between 2009 and 2012 as well as those services that were combined, 

or “bundled,” with another service during this time period. The codes we analyzed represented 171 of 

the 219 Current Procedural Terminology codes (78 percent) subject to the ADI accreditation 

requirement and 75 percent of ADI services subject to the requirement and provided to Medicare 

beneficiaries in 2012.

Effect of Accreditation 

Requirement on 

Access to Advanced 

Diagnostic Imaging in 

Office Settings Is 

Unclear in Context of 

Other Policy Changes
 

Page 11 GAO-14-378 Medicare Imaging Accreditation

The percentage decline in the number of ADI services provided in the 

office setting was generally similar in both urban and rural areas during 

the period we studied, although we found that substantially more services 

were provided in urban areas than in rural areas (see fig. 2). The number 

of ADI services per 1,000 FFS beneficiaries provided in urban areas 

declined by 7 percent between 2011 and 2012, while the number of 

services provided in rural areas declined by 8 percent. In addition, 148 

services were provided per 1,000 FFS beneficiaries in urban areas in 

2012, as compared to 81 services per 1,000 beneficiaries in rural areas. 

One reason the use of ADI services in the office setting was relatively low 

in rural areas was that a smaller percentage of ADI services in these 

areas were provided in the office setting. Specifically, in 2012, about 

14 percent of ADI services in rural areas were provided in the office 

setting, compared to 23 percent of ADI services in urban areas. See 

appendix I for trends in the number of urban and rural ADI services by 

modality.

Figure 2: Number of Advanced Diagnostic Imaging Services in the Office Setting 

per 1,000 Medicare Fee-for-Service Beneficiaries, by Urban/Rural Location, 2009-

2012

Notes: To examine the total number of advanced diagnostic imaging (ADI) services provided in the 

office setting per 1,000 Medicare fee-for-service beneficiaries, we calculated the number of claims for 

the technical component of computed tomography; magnetic resonance imaging; and nuclear 

medicine, including positron emission tomography services each year. We defined urban areas as 

those within a Metropolitan Statistical Area (MSA) and rural areas as those that were not located 
 

Page 12 GAO-14-378 Medicare Imaging Accreditation

within an MSA. Our results were limited to selected services subject to the ADI accreditation 

requirement. We excluded services that were not billed at least once each year between 2009 and 

2012 as well as those services that were combined, or “bundled,” with another service during this 

time period. The codes we analyzed represented 171 of the 219 Current Procedural Terminology 

codes (78 percent) subject to the ADI accreditation requirement and 75 percent of ADI services 

subject to the requirement and provided to Medicare beneficiaries in 2012.

The effect of accreditation on access—as illustrated by our analysis of the 

trends in ADI services in the office setting—is unclear in the context of 

recent policy and payment changes as well as other factors affecting the 

use of imaging services. In particular, the decline in ADI services 

occurred amid the implementation in recent years of public and private 

policies to slow rapid increases in imaging utilization and spending. 

Factors, including public and private policies, that may have played a role 

in the decline in ADI service utilization include the following:

• Medicare payment reductions. Reductions in Medicare payment 

may have contributed to the decline in ADI services between 2009 

and 2012 as reduced fees may affect physicians’ willingness to 

provide imaging services for Medicare beneficiaries.27

• Prior authorization. Studies have suggested that increased use of 

prior authorization policies among private payers in recent years has 

contributed to a decrease in ADI services provided to privately insured 

individuals.

For example, 

PPACA and ATRA reduced payment for the technical component of 

ADI services by adjusting assumptions related to the rate at which 

certain imaging equipment is used. In addition, CMS implemented a 

25 percent payment reduction for the professional component of 

certain CT and MRI services under the MPPR, effective January 1, 

2012—the same date the accreditation requirement went into effect.

28

 

27Some studies have also noted that payment reductions may result in providers 

increasing their volume of services to counter their loss in revenue from individual 

services. For example, see Congressional Budget Office, Factors Underlying the Growth 

in Medicare’s Spending for Physicians’ Services (Washington, D.C.: June 2007); and 

Stephen Zuckerman, Stephen A. Norton, and Diana Verrili, “Price Controls and Medicare

Spending: Assessing the Volume Offset Assumption,” Medical Care Research and 

Review, vol. 55, no. 4 (December 1998).

These policies may have had a spillover effect on 

Medicare, thus contributing to the decline in ADI services provided to 

Medicare beneficiaries from 2009 to 2012.

28For example, see Lee and Levy, “The Sharp Slowdown in Growth of Medical Imaging,” 

and J.M. Mitchell and R.R. LaGalia, “Controlling the Escalating Use of Advanced Imaging: 

The Role of Radiology Benefit Management Programs,” Medical Care Research and 

Review, vol. 66, no. 3 (2009).
 

Page 13 GAO-14-378 Medicare Imaging Accreditation

• Radiation awareness. Studies have suggested that increased 

physician and patient awareness of the risks associated with radiation 

exposure may have led to a decline in CT and NM services provided 

to Medicare beneficiaries.29

Although the effect of the accreditation requirement on access to ADI 

services in the office setting is unclear, in part because the requirement 

was implemented concurrently with other policy changes, CMS officials, 

accrediting organization representatives, and accredited ADI suppliers we 

interviewed suggested that any effect on access was likely limited. 

Specifically, CMS officials overseeing the accreditation requirement 

reported that they were not aware of any access to care issues resulting 

from the accreditation requirement and noted that there had been no 

beneficiary complaints regarding a lack of access to ADI services since 

the requirement went into effect. According to the officials, CMS 

performed outreach to ADI suppliers before the accreditation requirement 

went into effect to help ensure that it would not limit beneficiaries’ access 

to ADI services. In addition, most of the accredited suppliers we 

interviewed indicated that accreditation had not had a negative effect on 

beneficiary access to ADI services, with 17 out of 19 suppliers, including 

those located in urban and rural areas, reporting that accreditation had 

not affected the number of services they provided.30

 

29For example, see Lee and Levy, “The Sharp Slowdown in Growth of Medical Imaging,” 

and Harvey L. Neiman Health Policy Institute, Medical Imaging: Is the Growth Boom 

Over? (Reston, Va.: American College of Radiology, 2012). CT and NM services use 

ionizing radiation, thus exposing patients to the potential health risks associated with 

radiation, while MRI services do not.

Similarly, IAC and 

ACR representatives noted that the accreditation requirement likely had 

not had an adverse effect on beneficiary access to ADI services, and 

indicated that recent declines in imaging utilization largely stemmed from 

factors unrelated to accreditation, including reductions in Medicare and 

private payer reimbursement as well as increased awareness of the risks 

of radiation exposure. IAC and ACR representatives noted that the 

accreditation requirement may create a potential barrier for certain new 

ADI suppliers over time because they must provide imaging services 

without Medicare reimbursement for up to 6 months as they obtain the 

images and required documentation necessary to complete the 

30Of the remaining two suppliers, one indicated that it was unsure whether accreditation 

has affected the number of services it provides, while the other indicated that accreditation 

may have led to a slight increase in the number of services it provides.
 

Page 14 GAO-14-378 Medicare Imaging Accreditation

accreditation process.31 According to the representatives, IAC and ACR 

requested that CMS provide a provisional accreditation period for new 

suppliers that would allow them to obtain reimbursement for applicable 

ADI services while they undergo the accreditation process. According to 

CMS, it does not have the authority under MIPPA to provide provisional 

accreditation, as the statute only allows accredited suppliers to be paid for 

the technical component of ADI services beginning on January 1, 2012.32

We provided a draft of this report for review to the Department of Health 

and Human Services, and the agency stated that it had no comments.

We are sending copies of this report to the Secretary of Health and 

Human Services and appropriate congressional committees. The report 

will also be available at no charge on the GAO website at 

http://www.gao.gov. 

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made major contributions to 

this report are listed in appendix II.

James Cosgrove

Director, Health Care

 

31IAC and ACR require suppliers to submit, among other items, a sample of actual patient 

images in order to apply for accreditation. New ADI suppliers must therefore open 

facilities, hire staff, purchase imaging equipment, and provide imaging services until they 

obtain the necessary images to undergo the accreditation process. Suppliers are unable 

to receive reimbursement from Medicare for ADI services that are subject to the 

accreditation requirement until their accreditation has been approved.

32CMS does provide provisional accreditation for 120 days for accredited suppliers that 

purchase additional equipment or expand their services by adding locations or modalities.

Agency Comments
Page 15 GAO-14-378 Medicare Imaging Accreditation

List of Committees

The Honorable Ron Wyden

Chairman

The Honorable Orrin G. Hatch

Ranking Member

Committee on Finance

United States Senate

The Honorable Fred Upton

Chairman

The Honorable Henry A. Waxman

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Dave Camp

Chairman

The Honorable Sander M. Levin

Ranking Member

Committee on Ways and Means

House of Representatives
Appendix I: Advanced Diagnostic Imaging 

Services in Office Settings per 1,000 Medicare 

FFS Beneficiaries, 2010-2012

Page 16 GAO-14-378 Medicare Imaging Accreditation

Geographic 

designation Year

Computed 

Tomography (CT)

Magnetic 

Resonance 

Imaging (MRI)

Nuclear Medicine 

(NM)/Positron 

Emission 

Tomography (PET)

Urban 2009 57.3 96.7 19.7

2010 52.3 91.4 17.9

2011 50.3 90.8 17.3

2012 46.2 86.1 15.8

Rural 2009 33.4 55.2 12.0

2010 30.3 51.3 10.5

2011 28.8 49.5 10.0

2012 25.4 46.2 9.4

Source: GAO analysis of CMS data.

Notes: To examine the total number of advanced diagnostic imaging (ADI) services provided in the 

office setting per 1,000 Medicare FFS beneficiaries, we calculated the number of claims for the 

technical component of CT; MRI; and NM, including PET services each year. We defined urban areas 

as those within a Metropolitan Statistical Area (MSA) and rural areas as those that were not located 

within an MSA. Our results were limited to selected services subject to the ADI accreditation 

requirement. We excluded services that were not billed at least once each year between 2009 and 

2012 as well as those services that were combined, or “bundled,” with another service during this 

time period. The codes we analyzed represented 171 of the 219 Current Procedural Terminology 

(CPT) codes (78 percent) subject to the ADI accreditation requirement and 75 percent of ADI services 

subject to the requirement and provided to Medicare beneficiaries in 2012.

Appendix I: Advanced Diagnostic Imaging 

Services in Office Settings per 1,000 

Medicare FFS Beneficiaries, 2010-2012
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 17 GAO-14-378 Medicare Imaging Accreditation

James Cosgrove, (202) 512-7114 or cosgrovej@gao.gov

In addition to the contact named above, Phyllis Thorburn, Assistant 

Director; William Black, Assistant Director; Priyanka Sethi Bansal; 

William A. Crafton; Richard Lipinski; Beth Morrison; Jennifer Whitworth; 

and Rachael Wojnowicz made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(291121)
The Government Accountability Office, the audit, evaluation, and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and 

policies; and provides analyses, recommendations, and other assistance 

to help Congress make informed oversight, policy, and funding decisions. 

GAO’s commitment to good government is reflected in its core values of 

accountability, integrity, and reliability.

The fastest and easiest way to obtain copies of GAO documents at no 

cost is through GAO’s website (http://www.gao.gov). Each weekday 

afternoon, GAO posts on its website newly released reports, testimony, 

and correspondence. To have GAO e-mail you a list of newly posted 

products, go to http://www.gao.gov and select “E-mail Updates.”

The price of each GAO publication reflects GAO’s actual cost of 

production and distribution and depends on the number of pages in the 

publication and whether the publication is printed in color or black and 

white. Pricing and ordering information is posted on GAO’s website, 

http://www.gao.gov/ordering.htm. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 

TDD (202) 512-2537. 

Orders may be paid for using American Express, Discover Card, 

MasterCard, Visa, check, or money order. Call for additional information.

Connect with GAO on Facebook, Flickr, Twitter, and YouTube. 

Subscribe to our RSS Feeds or E-mail Updates. Listen to our Podcasts. 

Visit GAO on the web at www.gao.gov. 

Contact:

Website: http://www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470

Katherine Siggerud, Managing Director, siggerudk@gao.gov, (202) 512-

4400, U.S. Government Accountability Office, 441 G Street NW, Room 

7125, Washington, DC 20548

Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, DC 20548

GAO’s Mission

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Phone

Connect with GAO

To Report Fraud, 

Waste, and Abuse in 

Federal Programs

Congressional 

Relations

Public Affairs

Please Print on Recycled Paper.